04/19/23 1

Respiratory Disorders: Pleural and Thoracic Injury

I. Disorders of the Pleura

A. Pleural EffusionDefinition: a collection of

excess fluid in the pleural space.

04/19/23 2

04/19/23 3

Pleural effusion Chest x-ray of a pleural effusion. The arrow A shows fluid layering in the right pleural cavity. The B arrow shows the normal width of the lung in the cavity

04/19/23 4

Etiology of Pleural Effusions: Congestive Heart Failure Liver Disease Renal Disease Lupus, Rheumatoid Arthritis Pneumonia TB Lung Cancer Trauma

04/19/23 5

What would you think is happening in this client?

04/19/23 6

Answer:

Massive left sided pleural effusion in a patient presenting with lung cancer.

04/19/23 7

Pathophysiology of Pleural Effusion

capillary pressureor

plasma proteins

Formation of excess fluid=Transudate

capillary permeability=Exudate

Accumulation of pusin the pleural space=Empyema

04/19/23 8

Transudate vs Exudate

Non-inflammatory Trans means movement of

fluid due to changes in pressure gradients

What do you remember about oncotic pressure and serum albumin levels???

What is hydrostatic pressure?

Inflammatory in nature Exudate means there is a

release of fluid. Exudative pleural effusion

are due to changes in capillary permeability.

The capillaries are inflammed and are not as selective and allow fluid to leak into the pleural space.

04/19/23 9

Let’s try to classify Transudative or Exudative Pleural Effusion….

Etiology of Pleural Effusions: Congestive Heart Failure Liver Disease Renal Disease Lupus, Rheumatoid Arthritis Pneumonia TB Lung Cancer Trauma ARDS

04/19/23 10

Clinical Manifestationsof Pleural Effusion Dyspnea Pleurisy Decreased breath sounds Decreased chest wall movement

04/19/23 11

Diagnostic Tests Pleural Effusion CXR CT scan ABG’s/O2 Saturation

04/19/23 12

04/19/23 13

Therapeutic Interventions Thoracentesis-needle aspiration of fluid in

pleural space. Usually 1200-1500ml /time. Antibiotics if due to infectious process. Chest tube to drain fluid/air. Pleurodesis-instillation of chemical agent

(doxycycline) into pleural space to create inflammatory response (scar tissue) to adhese the visceral and parietal pleura.

Treat underlying condition that is causing the effusion.

Nursing Diagnosis #1Ineffective breathing pattern related to decreased lung expansion of left lung secondary to accumulation of fluid in the pleural space, pain and discomfort of breathing deeply secondary to inflammation and irritation of pleural space, and poor positioning in bed secondary to inability to reposition self without assistance.

Nursing Diagnosis #2Impaired gas exchange related to ineffective capillary – alveolar gas exchange secondary to presence of atelectasis in lower left lung and respiratory fatigue caused by presence of pleural effusion in left lung compromising ability to inspire deeply and causing pain.

PleurX® Pleural Catheter System

04/19/23 18

B. Spontaneous PneumothoraxDefinition-accumulation of air in the

pleural spacePathophysiology

Rupture of bleb on the lung surface allows air into the pleural space

• Primary pneumothorax- affects previously healthy individuals

• Secondary pneumothorax-affects individuals with preexisting lung disease

– Which diseases can you think of???

04/19/23 19

Clinical Manifestations of Spontaneous Pnemo Abrupt onset Pleuritic chest pain SOB, dyspnea respiratory rate, tachycardia Unequal chest excursion Decreased breath sounds on

affected side

04/19/23 20

C. Traumatic Pneumothorax

Definition/Pathophysiology: Accumulation of air into pleural space

due to blunt or penetrating trauma of chest wall/lungs.

Types of Traumatic Pneumothorax• Closed Pneumo• Open Pneumo• Iatrogenic Pneumo

04/19/23 21

Closed Pneumothorax

No opening from external chest.

Open Pneumothorax

Opening from external chest wall into pleura.

Iatrogenic Pneumothorax

Puncture or laceration of visceral pleura during medical tx

Occurs in crashes, falls, MVAs, CPR, fractured ribs that penetrate the pleura.

Occurs in stabbings, gunshot wounds, impalement injury.

Occurs in central line placement, thoracentesis, lung biopsy, bronchoscopy, & mechanical ventilation

04/19/23 22

I’m just asking…. The client has a spontaneous

pneumothorax….which type of pneumothorax is this:

A- Iatrogenic B- Open C- Closed D- Gee… I dunno

04/19/23 23

Clinical Manifestations of Pneumothorax Dyspnea Pleuritic Pain RR, pulse

respiratory excursion

Absent breath sounds on affected side

04/19/23 24

D. Tension Pneumothorax Definition: air/blood/fluid

rapidly enters pleural space and unable to escape

Lung collapses

Emergency situation!

04/19/23 25

Tension Pneumothorax

                           

Is this a right sided or left sided tension pnemothorax?

04/19/23 26

Pathophysiology of Tension Pnemothorax

Increase in Intrapleural pressure

Compression of lung to other side

Compresses against trachea, heart, aorta, esophagus

Ventilation and Cardiac Output greatly compromised

04/19/23 27

Clinical Manifestations/Complications of Tension Pneumo

Severe Dyspnea Tracheal Deviation Decreased Cardiac Output Distended Neck Veins RR, pulse, blood pressure

Shock

04/19/23 28

Therapeutic Interventions for Pneumothorax

High Fowlers position O2 as ordered Rest to decrease O2 demand Chest tube insertion Pleurodesis Surgery: Thoracotomy to remove blebs,

partial excision of parietal pleura done using VATS (video assisted thorascopic surgery)

04/19/23 29

II. Trauma of the Chest/Lung Chest injury is the leading cause of death

from trauma May involve chest wall, lungs, heart, great

vessels, esophagus Life threatening chest injuries include:

Airway obstruction Tension pneumo, open pneumo, massive

hemothorax Flail chest with pulmonary contusion

04/19/23 30

Pathophysiology of Thoracic Injury Acceleration-Deceleration Injury

Rapid change in velocity

Body stops suddenly

Chest cavity organs/tissues move forward

04/19/23 31

A. Rib Fracture

Simple rib fracture in an at risk client may lead to pneumonia, atelectasis, respiratory failure

Displaced rib fractures can result in pnemo/hemothorax, intrathoracic vessel tears, liver or spleen injury

04/19/23 32

Clinical Manifestations of Rib Fractures Pain on inspiration/coughing Voluntary splinting Rapid, shallow respirations Decreased breath sounds Crepitus on palpation Signs/symptoms of

pneumo/hemothorax

04/19/23 33

B. Flail Chest Etiology/Pathophysiology

Occurs when 2+ consecutive ribs are fractured in multiple places

Segment of chest wall becomes “free-floating” or flail

Flail segment of chest wall is sucked in during inspiration and moves outward with expiration

04/19/23 34

The client presents in the ED: Chest trauma client http://www.youtube.com/watch?v=PyDcGB-

i7OQ&feature=related

What did you note in this client? What would you do 1st? 2nd?

04/19/23 35

Clinical Manifestations of Flail Chest Dyspnea Pain especially on

inspiration Palpable crepitus Decreased breath sounds Unequal Chest expansion

04/19/23 36

What assessment finding is present???

                           

04/19/23 37

Flail Chest

Right lung affected

04/19/23 38

Therapeutic Interventions Flail Chest

O2 as ordered Elevate HOB Intercostal nerve block or epidural

analgesia to decrease pain Suction as ordered Splint affected area Preferred treatment= Intubation and

positive pressure ventilation

04/19/23 39

Internal/External fixation of ribs in

Flail Chest

04/19/23 40

Judet Plates for Fractured Ribs/Flail Chest

04/19/23 41

Sanchez Plates for Fractured Ribs/Flail Chest

04/19/23 42

C. Pulmonary Contusion Etiology/Pathophysiology

Left Pulmonary contusion

04/19/23 43

Abrupt Chest Compression thenRapid Decompression

Intra-alveolar Hemorrhage

Interstitial/bronchial Edema

surfactant production leads to decreased lung compliance

Airway obstruction, Atelectasis, Impaired O2/CO2 exchange

Pulmonary vascular resistance

blood flow

04/19/23 44

Clinical Manifestations of Pulmonary Contusion SOB

Restlessness, Anxiety Chest Pain Copius Sputum (blood tinged) RR, Pulse, Dyspnea, Cyanosis

04/19/23 45

Therapeutic Interventions Pulmonary Contusion Intubation/Mechanical Ventilation Bronchoscopy to remove secretions,

cellular debris Fluids, Volume expanders to treat shock Pulmonary Artery pressure monitoring